Phoenix Indian Center AmeriCorps Seniors Volunteer/Elder Mentorship Program Survey

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1. Personal Information (Required.)

Name

Address

City

State

ZIP

Email Address

Phone Number

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2. Tribal Affiliation (type N/A if not applicable) (Required.)

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3. Chapter House (if Navajo Nation Tribal Member)

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4. Age (Required.)

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5. Birthdate (Required.)

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6. Emergency Contact (Required.)

First Name

Last Name

Phone Number

Relationship

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7. Do you identify as: (Required.)

Identity as a member of the LGBTQ community

Does not identify as a member of the LGTBQ community

Two-Spirit

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8. Gender (Required.)

Male

Female

Gender Fluid/Does Not Identify as Male or Female

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9. Ethnicity (Required.)

Hispanic or Latino

Non-Hispanic or Non-Latino

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10. Racial Group (Required.)

Native American or Alaska Native

African American/Black

White/Caucasian

Asian/Asian American

Native Hawaiian or Other Pacific Islander

Two or More Races

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11. Are you a U.S. Veteran? (Required.)

Yes

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12. If yes, branch of service

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13. Are you an active member of the U.S. military? (Required.)

Yes

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14. If yes, branch of service

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15. Do you have any family members actively serving in the military? (Required.)

Yes

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16. Income level (Required.)

$24,999 or less

$25,000 to $39,999

$40,000 to $59,999

$60,000 to $74,999

$75,000 to $99,999

$100,000 to 149,999

$150,000 or more

Don’t know

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17. Housing (Required.)

Owned by mortgage or loan

Owned by without mortgage or loan

Rented

Occupied without payment or rent

Don’t know

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18. Availability (Required.)

	Mornings	Afternoons	Evenings
Monday	Monday Mornings	Monday Afternoons	Monday Evenings
Tuesday	Tuesday Mornings	Tuesday Afternoons	Tuesday Evenings
Wednesday	Wednesday Mornings	Wednesday Afternoons	Wednesday Evenings
Thursday	Thursday Mornings	Thursday Afternoons	Thursday Evenings
Friday	Friday Mornings	Friday Afternoons	Friday Evenings
Saturday	Saturday Mornings	Saturday Afternoons	Saturday Evenings
Sunday	Sunday Mornings	Sunday Afternoons	Sunday Evenings

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19. How many mentorship hours are you able to accommodate per month? (minimum of 10 hours per month required) (Required.)

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20. Why do you wish to be an Elder Mentor? (Required.)

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21. Do you have past experience working with youth? (Required.)

Yes

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22. If yes, what was your role/experience?

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23. How would you rate your technology abilities? (Required.)

Little to no knowledge

Expert

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24. Do you have reliable transportation? (Required.)

Yes

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25. If not, do you utilize public transportation?

Yes

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26. Describe any skills, education, accomplishments, spiritual knowledge/language that you possess (Required.)

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27. Are there any health issues, mobility issues, and/or accommodations that Phoenix Indian Center staff need to be aware of? (i.e. diet) (Required.)

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28. As an AmeriCorps Seniors volunteer, you will be covered by accident and personal liability insurance, and a small death benefit while performing volunteer duties. This coverage is automatic and free of cost to you as long as you are an active, enrolled member of AmeriCorps Seniors. Please provide the following info (Required.)

Beneficiary Name

Relationship

Beneficiary Phone

Beneficiary Address

City

State

Zip

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29. Are you willing to complete a fingerprint clearance and background check? (Required.)

Yes

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30. How did you hear about this opportunity? (Required.)

Outreach Table Event

Facebook

Instagram

Phoenix Indian Center website

Family/Friends

Flyers

Other (please explain)

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31. Do you prefer to do your interview via Zoom or In-Person at the Phoenix Indian Center. (Required.)

Zoom

In Person

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32. I understand that as an Elder Mentor, I will need to attend an orientation (Required.)

Yes

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33. I understand that as an Elder mentor, I will need to complete required background checks and fingerprint clearance (Required.)

Yes

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34. I understand that in my capacity as a Seniors Volunteer, I may come into contact with confidential information. I agree to protect this information to the best of my ability and not disclose it during or after my service as a volunteer had ended. (Required.)

Yes

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35. I understand that if I use my personal automobile in my volunteer service, I will keep in effect automobile liability insurance equal or greater to the minimum requirement of the state of Arizona. I will also keep a valid Arizona State drivers’ license. (Required.)

Yes

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36. Driver's License Information (Required.)

Driver's License

State

Expiration Date

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37. AmeriCorps Seniors provides mileage reimbursement to volunteers for travel between home and volunteer sites. Will you be claiming a mileage reimbursement for travel to and from your volunteer location? (Required.)

Yes

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38. If yes, is a copy of your proof of auto insurance showing active coverage attached?

Yes

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39. Proof of auto insurance

By signing below, I certify that the information completed in this application is correct to the best of my knowledge.

Phoenix Indian Center AmeriCorps Seniors Volunteer/Elder Mentorship Program

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* 1. Personal Information (Required.)

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* 2. Tribal Affiliation (type N/A if not applicable) (Required.)

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* 3. Chapter House (if Navajo Nation Tribal Member)

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* 4. Age (Required.)

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* 5. Birthdate (Required.)

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* 6. Emergency Contact (Required.)

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* 7. Do you identify as: (Required.)

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* 8. Gender (Required.)

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* 9. Ethnicity (Required.)

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* 10. Racial Group (Required.)

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* 11. Are you a U.S. Veteran? (Required.)

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* 12. If yes, branch of service

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* 13. Are you an active member of the U.S. military? (Required.)

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* 14. If yes, branch of service

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* 15. Do you have any family members actively serving in the military? (Required.)

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* 16. Income level (Required.)

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* 17. Housing (Required.)

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* 18. Availability (Required.)

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* 19. How many mentorship hours are you able to accommodate per month? (minimum of 10 hours per month required) (Required.)

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* 20. Why do you wish to be an Elder Mentor? (Required.)

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* 21. Do you have past experience working with youth? (Required.)

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* 22. If yes, what was your role/experience?

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* 23. How would you rate your technology abilities? (Required.)

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* 24. Do you have reliable transportation? (Required.)

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* 25. If not, do you utilize public transportation?

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* 26. Describe any skills, education, accomplishments, spiritual knowledge/language that you possess (Required.)

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* 27. Are there any health issues, mobility issues, and/or accommodations that Phoenix Indian Center staff need to be aware of? (i.e. diet) (Required.)

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* 29. Are you willing to complete a fingerprint clearance and background check? (Required.)

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* 30. How did you hear about this opportunity? (Required.)

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* 31. Do you prefer to do your interview via Zoom or In-Person at the Phoenix Indian Center. (Required.)

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* 32. I understand that as an Elder Mentor, I will need to attend an orientation (Required.)

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* 33. I understand that as an Elder mentor, I will need to complete required background checks and fingerprint clearance (Required.)

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* 34. I understand that in my capacity as a Seniors Volunteer, I may come into contact with confidential information. I agree to protect this information to the best of my ability and not disclose it during or after my service as a volunteer had ended. (Required.)

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* 35. I understand that if I use my personal automobile in my volunteer service, I will keep in effect automobile liability insurance equal or greater to the minimum requirement of the state of Arizona. I will also keep a valid Arizona State drivers’ license. (Required.)

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* 36. Driver's License Information (Required.)

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* 37. AmeriCorps Seniors provides mileage reimbursement to volunteers for travel between home and volunteer sites. Will you be claiming a mileage reimbursement for travel to and from your volunteer location? (Required.)

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* 38. If yes, is a copy of your proof of auto insurance showing active coverage attached?

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* 39. Proof of auto insurance

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* 40. Print Name (Required.)

1. Personal Information (Required.)

2. Tribal Affiliation (type N/A if not applicable) (Required.)

3. Chapter House (if Navajo Nation Tribal Member)

4. Age (Required.)

5. Birthdate (Required.)

6. Emergency Contact (Required.)

7. Do you identify as: (Required.)

8. Gender (Required.)

9. Ethnicity (Required.)

10. Racial Group (Required.)

11. Are you a U.S. Veteran? (Required.)

12. If yes, branch of service

13. Are you an active member of the U.S. military? (Required.)

14. If yes, branch of service

15. Do you have any family members actively serving in the military? (Required.)

16. Income level (Required.)

17. Housing (Required.)

18. Availability (Required.)

19. How many mentorship hours are you able to accommodate per month? (minimum of 10 hours per month required) (Required.)

20. Why do you wish to be an Elder Mentor? (Required.)

21. Do you have past experience working with youth? (Required.)

22. If yes, what was your role/experience?

23. How would you rate your technology abilities? (Required.)

24. Do you have reliable transportation? (Required.)

25. If not, do you utilize public transportation?

26. Describe any skills, education, accomplishments, spiritual knowledge/language that you possess (Required.)

27. Are there any health issues, mobility issues, and/or accommodations that Phoenix Indian Center staff need to be aware of? (i.e. diet) (Required.)

29. Are you willing to complete a fingerprint clearance and background check? (Required.)

30. How did you hear about this opportunity? (Required.)

31. Do you prefer to do your interview via Zoom or In-Person at the Phoenix Indian Center. (Required.)

32. I understand that as an Elder Mentor, I will need to attend an orientation (Required.)

33. I understand that as an Elder mentor, I will need to complete required background checks and fingerprint clearance (Required.)

34. I understand that in my capacity as a Seniors Volunteer, I may come into contact with confidential information. I agree to protect this information to the best of my ability and not disclose it during or after my service as a volunteer had ended. (Required.)

35. I understand that if I use my personal automobile in my volunteer service, I will keep in effect automobile liability insurance equal or greater to the minimum requirement of the state of Arizona. I will also keep a valid Arizona State drivers’ license. (Required.)

36. Driver's License Information (Required.)

37. AmeriCorps Seniors provides mileage reimbursement to volunteers for travel between home and volunteer sites. Will you be claiming a mileage reimbursement for travel to and from your volunteer location? (Required.)

38. If yes, is a copy of your proof of auto insurance showing active coverage attached?

39. Proof of auto insurance

40. Print Name (Required.)

41. Today's Date (Required.)